그들은 원치 않았다: 아이티 청년을 향한 성과 성별에 기반한 폭력

AGAINST THEIR WILL SEXUAL AND GENDER BASED VIOLENCE AGAINST YOUNG PEOPLE IN HAITI

July 2017

CONTENTS INTRODUCTION

1

EXPOSURE OF YOUNG PEOPLE TO SEXUAL AND GENDER BASED VIOLENCE 1.1 Exposure of young people below the age of 25 years 1.2 Exposure of minors (below 18 years) 1.3 Exposure of boys and men 1.4 Rape as main form of SGBV 1.5 Lack of information on SGBV 1.6 “He lived in our Neighborhood” Sexual assaults by known perpetrators

CREDITS © 2017 Médecins Sans Frontières/ Doctors Without Borders All images © Benedicte Kurzen Cover image: MSF has opened a SGBV clinic in Port au Prince Haiti in May 2015: Pran Men’m (Haitian creole for “take my hand”). From May 2015 to March 2017, MSF’s Pran Men’m clinic has provided care to close to 1,300 SGBV survivors. MSF works with a network of local organisations, including Solidarité fanm pou yon lavi miyò (Sofalam) to address the issue of SGBV. Art Direction & Design: Atomodesign.nl Médecins Sans Frontières Plantage Middenlaan 14

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1018 DD Amsterdam

NEED FOR COMPREHENSIVE MEDICAL CARE 2.1 Urging medical services to be accessible at all times for SGBV survivors 2.2 Recognising the health consequences of SGBV 2.3 “Her body was changing” Early Unintended Pregnancies 2.4 “Her entire body was marked” Connecting rape to physical violence to SGBV 2.5 “Sometimes sad, sometimes depressed” Mental health consequences

Netherlands

T +31 20 520 8700 E info@amsterdam.msf.org W www.msf.org www.facebook.com/msf.english www.twitter.com/MSF

SCARCITY OF SERVICES FOR SURVIVORS 3.1 The lack of shelter and short-term safe houses for survivors

CONCLUSION AND RECOMMENDATIONS

Gisele , 20 years old, SGBV survivor (name changed) “He took me to an isolated place and asked me to get naked. He touched me and raped me. I even gave him 1000 gourds.”

2 AGAINST THEIR WILL

AGAINST THEIR WILL 3

INTRODUCTION

“He had already told me before that he wanted to do what he did to me, but I never believed he would really do it. He took me to an abandoned house.

This is where it happened. He knew my parents, and threatened to kill me if I told them the truth.”

– Natacha1, 22 years old

Natacha’s2 story is similar to that of thousands of young people who face sexual and gender-based violence (SGBV) in Haiti.

Today, the number of young people, and specifically girls and women, who report experiencing violence, continues to be alarmingly high, especially in the densely populated capital city, Port-au-Prince. Yet the issue is still not widely discussed in Haiti, and incidents of SGBV are likely underreported due to stigma and shame, as well as fear of reprisals from perpetrators or from the community. While SGBV is considered by many aid organizations, government agencies and other stakeholders to be a widespread problem, the full picture remains challenging. Official statistics do not exist on the scale of violence against young people and specifically violence against girls and women in Haiti.3 Nonetheless, available evidence suggests that 28% of women aged 15-49 reported having experienced physical violence, and more than one in 10 Haitian women have faced sexual violence at some point in their lives.4 Data about sexual violence against children younger than 15 is even more difficult to capture.

The current availability of multi-disciplinary services for survivors is inadequate to address their needs or the problem of SGBV more generally, especially when it comes to children and young people. Despite progress in some sectors and ambitious efforts from some civil society actors, government policy and overall capacity still lags well behind the needs.

Survivors of SGBV often fall between the cracks of a poorly coordinated system that should be providing them with an integrated package of medical and psychological care, as well as social and legal support and protection. The experiences of Natacha, Marie, Viviane, Gisele, Sarah, Madeleine, Jeanne and Solange5 included in this report are a glimpse of the experiences of many other survivors whose voices are not heard. Direct testimonies from survivors below the age of 18 are not included, so as to respect their specific vulnerability and legal status as minors. However, sexual violence against minors (less than 18 years of age) is a real issue in Haiti, one that Médecins Sans Frontières (MSF) doctors and psychologists speak out about in this report in order for these young survivors not to remain voiceless.

In May 2015, MSF joined other agencies serving survivors of sexual violence in Haiti by opening a clinic specialized in providing medical and psychosocial care for people affected by SGBV in Port-au-Prince. Since its opening, from May 2015 to March 2017, MSF’s Pran Men’m clinic (Haitian creole for “take my hand”) has provided care to close to 1,300 SGBV survivors, most of whom are minors or young women under the age of 25. Stories and data presented here show that the caseload at MSF’s clinic is consistent with existing reports of high levels of sexual and gender-based violence in the country, and that there is an urgent need to scale up services for survivors.

Name has been changed to protect patient’s anonymity.

Name has been changed to protect patient’s anonymity.

3 HRS, 2012 4 Cayemittes, 2012 5 Names have been changed to protect patients’ anonymity.

1 2

AGAINST THEIR WILL 5

EXPOSURE OF YOUNG PEOPLE TO SEXUAL AND GENDER BASED VIOLENCE

1 6 AGAINST THEIR WILL

“I met this guy on the street. We started to chat.

After a while I told him I was looking for a job.

He immediately said that one of his friends was precisely looking for someone like me. He said that he needed to go to his place to pick up some documents. When we got there he pulled out his gun. This is when it happened.”

– Marie6, 21 years old

1.1 Exposure of young people below the age of 25 years Since the opening of Pran Men’m clinic, MSF has witnessed a steady and constant increase in the number of patients seen every month. While SGBV is considered to be widespread, girls and young women appear to be the most vulnerable. Patients younger than 25 years of age represent the vast majority of all survivors that MSF has treated from May 2015 to March 2017 (77%).

1.2 Exposure of minors (below 18 years) MSF is particularly concerned by the fact that 53% of patients seen between May 2015 and March 2017 in Pran Men’m clinic are under 18, most of whom are survivors of rape and other types of sexual abuse. MSF treats without distinction of age or gender all survivors in its clinic, but the high numbers of survivors under the age of 18 emphasizes the urgent need to address the problem of SGBV against minors, whose vulnerability to sexual abuse is higher due to their young age.

1.3 Exposure of boys and men Although 97% of MSF’s patients are female, and this report focuses on girls and young women, SGBV also affects men and boys. The Pran Men’m clinic has so far (from May 2015 to March 2017) treated 33 male SGBV survivors. Of this group, 23 patients (70%) were minors, including 13 patients under the age of 10 and seven patients between 10 and 14 years of age.

Given the risk of stigma that contributes to the general underreporting of sexual violence in Haiti, men and boys are even less likely to report incidents or seek the medical care and other support they need after an incident of sexual assault.

1.4 Rape as main form of SGBV SGBV can take several forms, including discrimination, intimidation and physical and sexual violence. The latter encompasses rape, which is the primary reason for survivors to seek care at MSF’s clinic. More than 83% of all patients are rape survivors, of whom 83% are younger than 25 years of age.

Rape survivors by age range May 2015 - March 2017

> 25 yo 17%

> 10 yo 14%

10 -14 yo 20%

18 - 24 yo 26%

6

15 -17 yo 23%

Name has been changed to protect patient’s anonymity.

AGAINST THEIR WILL 7

Marie, SGBV survivor, 21 years old “I met this guy on the street. We started to chat. [...]

He said that he needed to go to his place to pick up some documents. When we got there he pulled out his gun. This is when it happened.”

this fundamental barrier to young girls and boys protecting themselves and seeking the care they need when an incident does happen. But the current lack of information increases the vulnerability of minors to sexual abuse, and can lead to situations where minors are perpetrators themselves. More than half of survivors younger than 10 years of age treated

1.6 “He lived in our Neighborhood” Sexual assaults by known perpetrators “He was someone we knew. He lived near us in the camp. Our tent was broken and had a big hole in it.

He came through it. He raped Sarah. She was on her own. Sarah wanted to dance, she loved it but I don’t want her to. I feel she is too visible when she dances.

Now she stays most of the time with my nieces.”

ESENTIAL MEDICAL AND PSYCHOLOGICAL SERVICES FOR SURVIVORS

Psychological support

Medical first aid

– Mother of Sarah9 (13 years old)

“My cousin told me that I had bad luck, that something was wrong with me. A friend of my parents said that he was a mason and therefore could help remove the ‘bad eye.’ He took me to an isolated place and asked me to get naked. He touched me and raped me. I also know he is a recidivist. He did the same to two little girls from my neighbourhood. The parents are scared so they don’t do anything. The girls are 15 and 12.”

– Gisele7, 20 years old

1.5 Lack of information on SGBV “The boy was a friend from school. He took me to his home, to give me one of his books. I kept asking if his dad was there. He said yes. When I arrived the house was empty. He took me to his room and forced me.”

Four out of five minors who have experienced SGBV knew their attackers. Most were family acquaintances, and sometimes (11% of the time) they were household members. Most children under 10 years of age (71%) were abused in places where they should feel safe, such as their own homes, or with friends and relatives.

Children and adolescents are often left on their own while their caretakers are working or meeting the needs of their household.

Most minors coming to Pran Men’m clinic were abused during the day, when they were away from their parents’ attention.

– Viviane8, 22 years old

When Viviane told her story, she pointed out that this boy she knew from school was acting as if he did not know he was doing something wrong. Yet, she understood what happened to her, while younger ones might not. Sexual reproductive health education is not well covered in the educational curricula in Haiti. Some young people have access to informal sexual education from civil society organizations, and several women’s groups advocate for the better inclusion of sexual education in formal education curricula, to help overcome

Medicine to prevent HIV infection and prevent or treat other sexually transmitted infections (STIs)

Vaccinations to prevent hepatitis B and tetanus

Emergency contraception to prevent unwanted pregnancies as a result of rape

Name has been changed to protect patient’s anonymity.

Name has been changed to protect patient’s anonymity.

9 Name has been changed to protect patient’s anonymity.

7 8

AGAINST THEIR WILL 9

Sarah (name changed) is a 13 years old teenager that has been raped by someone she knew. Her story shows that SGBV is a medical emergency in Haiti.

Stephanie (name changed), 52 years old, is a survivor of SGBV who got assistance at the MSF clinic Pran Men’m. She was beaten up and raped. She is worried that she will become blind.

“I had a boyfriend but we were seperated. He had a lot of other girlfriends and also children. I even look after one of his boy and also one of his daughters now. She is like my own. One night, he came to my place and we fought. He threw me on the floor and raped me so brutally that I started to bleed. My daughters and children don’t know what happened. I did not tell them anything. I pretended the blood was something else. After a couple of days, I decided to go to the MSF clinic. It is passed now, and my only worry is actually not the rape, it is to become blind; I have eyes problem. If I can’t see anymore, I can’t help my family anymore. This worries me a lot.”

10 AGAINST THEIR WILL

“He is someone we knew. He lived in the same area than us in the camp. Now he is nowhere to be found. Our tent was broken and had a big hole in it. he came through it.

He rape Sarah. She was on her own. Sarah wants to dance, she loves it but I don’t want her to. I feel she is too visible when she dances. Now she stays most of the time with my nieces.”

AGAINST THEIR WILL 11

NEED FOR COMPREHENSIVE MEDICAL CARE

2 12 RETURN TO ABUSER

“MSF doctors really helped me; I was really very well taken care of. I have a friend who also had a problem and who went to another clinic; when I told her about the care I received, she said I was very lucky to have gone to MSF.” – Madeleine10, 23 years old

“We had to transfer a 12 year-old patient who had been raped by a family acquaintance to our obstetric hospital; 11 she has terrible tearing and bleeding that required immediate surgery. The scars on her body made us immediately understand that she was abused for years. Even though our gynecologists have dealt with emergencies for many years, they were shocked.”

Madeleine’s friend maybe felt she was not fully taken care of at – Marine, MSF medical coordinator another clinic. Indeed, most facilities in Haiti cannot provide the full range of services needed to address SGBV. Medical When survivors receive medical care as soon as possible within care provision is often incomplete.

72 hours, many of these risks can be reduced or eliminated.

Post-Exposure Prophylaxis (PEP) for the prevention of 2.1 Urging medical services to be HIV infection has to begin within 72 hours after the assault. accessible at all times for SGBV survivors Although emergency contraception can be offered up to 120 hours after the event, it is most effective in the first three days.

Medical providers in Haiti often do not stay open 24 hours a day or seven days a week, which presents a barrier for survivors to access the care they need. From May 2015 to March 2017, close to 38% of rape survivors come to MSF’s Pran Men’m clinic between 6pm and midnight, when most other clinics offering SGBV care are closed.

To further ensure 24/7 support to SGBV survivors, MSF partners since March 2017 with the local organization Promoteurs Objectif Zéro-Sida (POZ) that operates a free-ofcharge hotline - “Téléphone Bleu”. Initially intended to provide counselling on HIV-AIDS and family planning, the hotline now provides additional advice and orientates SGBV survivors to adequate services, including to MSF’s Pran Men’m clinic.

“I remember this 13-year-old girl who came with her mother. I immediately saw she was pregnant.

She did realize her body was changing, but she did not understand what happened to her: neither the rape, nor that she was carrying a baby. She did not say anything to her mother for too long.

The mother was devastated.”

– Judith, MSF doctor

2.3 “Her body was changing” Early Unintended Pregnancies

Although family planning is quite easily available in health structures, many Haitian women do not to use it, 2.2 Recognising the health either because of cultural and religious norms, or due to consequences of SGBV common misconceptions about secondary effects. Nearly 64% of Haitian women under 20 years old report that their Every day, MSF’s clinicians witness the health consequences of SGBV in Haiti. Sexual violence can be a cause of HIV transmission pregnancies were unintended.12 and other sexually-transmitted infections. It can lead to unwanted pregnancies, which for many of MSF’s young patients has grave life-changing consequences. Survivors often have physical injuries (bruises, lacerations, stabbing, fractures), and sexual violence can 10 Name has been changed to protect patient’s anonymity.

11 cause vaginal or anal tearing, bleeding or infection.

MSF runs an emergency obstetrics hospital in Port-au-Prince 12

(same neighborhood as the Pran Men'm clinic) since 2011.

Cayemittes et al, 2012

AGAINST THEIR WILL 13

Gisèle, 20 years old, SGBV survivor (name changed) “He touched me and raped me”.

2.4 “Her entire body was marked” Connecting rape to physical violence to SGBV

“There was this 12-year old girl who arrived with her mother. As I was trying to talk with her before examining her, she could not stop crying. I asked the mother to go out. When she opened her shirt, I was horrified: her entire body was marked by assault and battery. I have examined lots of physical violence survivors in my life, but I swear, I never saw wounds like these. Her mother had beaten the daughter extremely violently when she told her she had been sexually abused. I immediately called the psychologist to counsel both for the mother and the girl.”

“One night, I heard lots of noise close to my house.

Somebody knocked on my door. Ten men entered, asking for money. I didn’t have any. They said they would kill me. One of the men then hit my head with his gun. They took me outside, repeating they would kill me. They said the 10 of them would rape me. When I prayed to the Lord to help me, one of them got angry at my prayers and hit me again. They – Judith, MSF doctor started to discuss if all the 10 of them would rape Experiencing violence in childhood, particularly sexual violence, me. Four men stayed; the four raped me.”

– Joanne13, 36 years old

Haiti is a country that has been marked by several waves of political, urban and social violence, and where gender imbalances are still prevalent within society and communities. Rape survivors who have received care from MSF, like Joanne, were often exposed to violence and threats, including with the use of weapons.

From May 2015 to March 2017, MSF’s Pran Men’m clinic has treated 45 pregnant minors (including 17 pregnant girls aged 10 to 14 years) and 30 pregnant adults who, due to late arrival at the clinic, were not able to use emergency contraception. Pregnancies at an early age are high-risk ones, and risks are further exacerbated by the stigma of carrying a post-rape child and the recurrent socioeconomic vulnerability of these girls, both of which may lead survivors to avoid seeking proper antenatal care.

“Minors who are pregnant as a consequence of rape adopt various defensive strategies. Some of them are in a state of emotional anaesthesia [inability to express emotions], but there are lots of possible reactions that emphasize the psychological consequences these girls struggle with. I remember a teenager who was punching her belly; another one who refused to touch her belly or to shower; another one who refused to eat, hoping it would kill the baby inside.”

MSF clinicians often treat survivors of both sexual abuse and physical violence, especially the youngest ones. Even after initial incidents of abuse, many minors continue to be exposed to physical violence. Children often do not talk after an incident because they do not understand it, or because they feel guilty about what happened to them. Their silence is sometimes misinterpreted as acceptance by their guardians.

One in five minors who came to MSF’s Pran Men’m clinic after sexual abuse was previously exposed to SGBV.

– Stephanie, MSF psychologist

is a risk factor for violence in adulthood.14 As such, survivors require adequate medical assistance and psychological support to address both their immediate need for assistance and long-term physical and mental health consequences.

2.5 “Sometimes sad, sometimes depressed” Mental health consequences “There is a high risk of being further exposed to violence if the survivor does not receive adequate psychological care, because she will not realize that she is again a victim. When psychological support is delivered on time, the survivor is empowered and knows that violence, including sexual abuse, is not acceptable. This is particularly critical for the youngest ones.”

– Stéphanie, MSF psychologist

“When I got back home, I told my parents I had been raped but I couldn’t tell them what happened exactly. I didn’t know what to say, I was so ashamed. I ran away to my aunt’s and told her everything. She told the story to my parents and they accepted to take me to the hospital. I was transferred to Pran Men’m clinic.”

– Madeleine15, 23 years old

Name has been changed to protect patient’s anonymity.

Dunkle, 2004 15 Name has been changed to protect patient’s anonymity.

13 14

14 AGAINST THEIR WILL

AGAINST THEIR WILL 15

Immediately after sexual attacks, survivors are often in a state of shock; some may feel guilty, believing they could have avoided the rape. Rape survivors can also develop depression and post-traumatic stress disorder. The first objective of psychosocial care for survivors is to help them restore their abilities to carry on with their lives. In some cases, when patients arrive in a state of shock, initial counselling helps stabilize and prepare them to receive medical care.

“I cried a lot when I arrived in the clinic. MSF’s support helped me to overcome this. Since then, I am in a better mood, but I still have difficulties with hobbies such as reading or listening to music.

Now, I am sometimes sad, sometimes depressed… and I often fake being strong.”

– Natacha16, 22 years old

Natacha17 was raped more than a one and a half years ago, but she is still suffering from the consequences and attends counselling sessions with MSF psychologists. Timely counselling and adequate follow-up sessions help prevent longlasting psychological consequences. “One occurrence of sexual aggression may be sufficient to create long-lasting negative effects, especially if the child-victim does not subsequently receive appropriate support. Like violence against women in the family, child abuse often continues for many years, and its disabling effects can carry over into adult life. For example, the reduced self-esteem of women who have been abused in childhood may result in their making little effort to avoid situations where their health or safety are in jeopardy”.18

Survivors and their caretakers need to understand the health consequences of SGBV, the risks they face and where to find treatment as soon as possible after an incident, so they can prevent as many of the negative health consequences possible.

For this reason, MSF has a dedicated IEC (information education and communication) team who actively engages with community organizations and schools to create awareness about the health consequences of SGBV. These teams emphasize that SGBV incidents can happen to anyone, and the need for timely medical care. Thanks to these sensitization efforts, attendance at the clinic has increased steadily, especially by minor survivors. Specific sessions aimed at increasing minors’ understanding of sexual abuse are necessary to ensure that survivors can speak to their legal guardian about their abuse to be able to seek care in a timely manner.

“There is quite a different approach towards minors under the age of 10 and those who are older. For the youngest ones, we rely a lot on recreational activities such as songs, games, stories and role plays. Our key messages are ‘my body is my body’ and ‘good secrets, bad secrets’. The trickiest topics to deal with are gender equity and norms, especially with adolescents.”

– Susanne, MSF health promoter

“Talking about sexuality is very sensitive in Haiti. Finding solutions to sexual violence should involve community actors, [so] we inform members of the community about the existence of the Pran Men’m clinic.”

– Yves, MSF health promoter

“For me, the most difficult cases are always the youngest ones. The medical examination can be painful for young children. Some of them refuse to be touched, even by a doctor. They need to feel safe, trusted, that they won’t be hurt anymore. I always work very closely with the psychologist.”

MSF has opened a SGBV clinic in Port au Prince Haiti in May 2015: Pran Men’m (Haitian creole for “take my hand”). From May 2015 to March 2017, MSF’s Pran Men’m clinic has provided care to close to 1,300 SGBV survivors. MSF works with a network of local organisations, including Solidarité fanm pou yon lavi miyò (Sofalam) to address the issue of SGBV.

– Judith, MSF doctor Name has been changed to protect patient’s anonymity.

Name has been changed to protect patient’s anonymity.

18 WHO, 1997 16 17

16 AGAINST THEIR WILL

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SCARCITY OF SERVICES FOR SURVIVORS

3 18 RETURN TO ABUSER

“I started studying law, but I failed my exams.

My mother keeps crying all the time and feels guilty about what happened to me.”

– Natacha19, 22 years old

The consequences of SGBV are physical and psychological, but they are also social and economic. SGBV affects not only the survivors, but also their families and communities.

Survivors need comprehensive care, which includes a range of support services.

for young survivors. Minors are also often referred by nongovernmental organizations (23%) with which MSF collaborates, while 14% come to the clinic spontaneously.

“The day after I got raped, I went to the police, who gave me a paper with information about the clinic.

I had never heard of it before, but I went directly.”

– Natacha21, 22 years old

More than 25% of adult SGBV survivors are referred to the clinic by the police, which MSF believes indicates a Before the 2010 earthquake, SGBV prevention and care services recognition by the public and the police of the importance of a rapid and multi-sector response to the issue of SGBV. were more numerous in Haiti, and activism from local civil It could also suggest that some of these young women were society actors was showing results. In 2005, with the help of confident enough to go to the police after sexual abuse.

Haitian women’s groups, the Concertation Nationale (“National Dialogue” in French) was launched and led to the criminalization It enabled Natacha22 and many other women to seek care at MSF’s clinic in a timely fashion after rape. of rape with a sentence ranging from 10 years to life. That same year marked the first time that the categorization of rape in the Haitian Criminal Code changed from a crime against morals to a crime against the person. Until then, sentencing was lenient and there was no victim protection.20 Medical assistance The arrival of dozens of international agencies in the postearthquake era created competition for local and communitybased services. When these international organizations began to leave, local organizations were left with limited options Legal Psychological counselling or leverage to access international funding in order to keep support providing services. There is a full range of public and civil society actors involved in the response to SGBV, but most have resources that are too sparse to ensure continuous services. Coordination of existing services for survivors is one of the biggest challenges, and there is a significant gap in service provision in all sectors.

Social and economic Protection Since the opening of its Pran Men’m clinic, MSF has collaborated inclusion with a wide range of public and civil society actors to help ensure our patients receive all the support services they need.

From May 2015 to March 2017, 47% of patients under 18 years of age are referred by the police to Pran Men’m clinic, especially the Minors’ Protection Brigade. Their collaboration has been instrumental for ensuring timely medical and psychological care

Name has been changed to protect patient’s anonymity.

Nolan, 2011 21 Name has been changed to protect patient’s anonymity 22 Name has been changed to protect patient’s anonymity.

19 20

AGAINST THEIR WILL 19

Gisele , 20 years old, SGBV survivor (name changed) “He touched me and raped me”.

3.1 The lack of shelter and short-term safe houses for survivors “Sometimes, we’re obliged to keep survivors in our clinic while we seek a suitable solution for them; they cannot go back to their communities where their perpetrators also live.”

– Judith, medical doctor

The fact that many cases of abuse are perpetrated by neighbours, acquaintances or even family members often prevents survivors from returning to their homes and communities, where they remain at risk of further violence and stigma, and sometimes reprisals from their perpetrators. MSF works with a network of local organisations providing social and protection services for young girls and vulnerable children, as well as adult women who have been abused. They provide shelter to minors, women and families who have been referred to them by governmental social agencies, by MSF or by other partners. But procedures for placement are often lengthy due to the scarcity of existing structures, especially for families and women. MSF has often had to find a way of providing shortterm shelter for survivors until a better solution can be found.

Longer-term, safe and secure shelter solutions remain one of the greatest and most urgent needs for our patients.

“I have three children. I lived in Pétionville. I was in my house and late at night, two men showed up.

They raped my daughter and me. I went immediately to the MSF clinic. They hit my head a lot as I wanted them to rape me but not my daughter. One month later, they burnt the house of my mother, to intimidate me. I have to run away, and take refuge here as my attackers are still around. They took everything. My head is constantly hurting, so I go to the clinic twice a month.”

– Jeanne23, 31 years old, and Solange24, 16 years old

20 AGAINST THEIR WILL

The most vulnerable patients need to be referred to social services for follow-up and protective care, to avoid further exposure to violence or sexual abuse. Jeanne25 wanted to protect herself and her daughter from their attackers, but had nowhere to go and was out of resources to move forward. Of the patients cared for in the Pran Men’m clinic from May 2015 to March 2017, 67% are in need of social support. Of these, 49% are in need of protection (including safe shelter and child protection services). Out of the total number of survivors, 28% have been referred for legal assistance to press charges against perpetrators.

Despite the enormous need for social and protection services, there is a huge constraint due to lack of sustainable funding and proper referral mechanisms to ensure comprehensive care.

“Minors often don’t understand what happened to them; they know it is not normal, but they don’t understand the abuse itself. Adolescents often don’t measure the consequences, notably social ones.”

– Stéphanie, MSF psychologist

Name has been changed to protect patient’s anonymity.

Name has been changed to protect patient’s anonymity 25 Name has been changed to protect patient’s anonymity.

23 24

AGAINST THEIR WILL 21

© Jodi Bieber

CONCLUSION AND RECOMMENDATIONS

4 22 RETURN TO ABUSER

Sexual and gender-based violence is a significant problem in Haiti and must be recognized as a public health issue. Survivors must have access to adequate medical and psychological care.

■ It is essential to increase prevention at various levels, and to reinforce rapid availability and accessibility of medical and psychological care for survivors, as well as social support and protection services.

■ S GBV prevention programs targeting children and young adults should be reinforced in Haiti. Sexual education should be better included in primary and especially secondary school curricula.

As long as the above points remain unaddressed, SGBV will continue to be a critical issue in Haiti, especially for children and young people.

■ I n order to respond to the specific needs of medical and

psychological care for SGBV survivors, targeted training and development of health professionals is necessary.

■ E mergency contraception, vaccines (hepatitis B, tetanus)

and medicines for the prevention of HIV and other sexually transmitted infections should be available in health structures and easily accessible for rape survivors.

■ T o ensure that the health needs of survivors of sexual violence are fully addressed, adequate, timely and free of charge emergency medical and psychological care should be easily accessible for all rape survivors.

■A referral network of service providers for SGBV survivors,

efficiently coordinated at national and local levels, is urgently needed. This will ensure that any survivor seeking assistance is being properly referred to a comprehensive range of services.

■D onors need to support organizations which support the

multi-disciplinary response including protection programs with safe shelter solutions, with more sustainable and reliable funding to ensure the protection of the most vulnerable survivors. Donors also need to support sexual education programs in schools.

Médecins Sans Frontières (MSF) is an international, independent, medical humanitarian organisation that delivers emergency aid to people affected by armed conflict, epidemics, natural disasters and exclusion from healthcare in over 70 countries. We offer assistance to people based on need and irrespective of race, religion, gender or political affiliation.

MSF has been present in Haiti for over 19 years, providing free healthcare for the thousands of people who cannot afford the limited healthcare available. MSF currently runs five projects in the Port-au-Prince metropolitan area, including the Drouillard hospital for severe burns, the Tabarre traumatology hospital, the Martissant emergency centre, the Centre de Référence des Urgences en Obstétrique (CRUO) for emergency obstetric and neonatal care, and the Pran Men’m clinic for survivors of sexual and gender-based violence. MSF also supports the MSPP-led Port-à-Piment hospital (Sud department). MSF responded to the needs of the population affected by Hurricane Matthew in October 2016 in three departments (Grande Anse, Sud and Nippes). The organization maintains its capacity to respond to medical-humanitarian emergencies throughout the country.

■ P roviding multidisciplinary services to survivors is critical to address their immediate needs, as well as the long-term consequences of SGBV.

AGAINST THEIR WILL 23

GLOSSARY Sexual and Gender Based Violence: MSF uses the UNHCR definition of SGBV: SGBV refers to any harmful act that is perpetrated against one person’s will and that is based on socially ascribed (gender) differences between males and females. It includes acts that inflict physical, mental, or sexual harm or suffering, threats of such acts, coercion and other deprivations of liberty, whether occurring in public or in private life1.

A wide range of sexually violent acts can take place in different circumstances and settings. These include, but are not limited to: rape within marriage or dating relationships; rape by strangers; systematic rape during armed conflict; unwanted sexual advances or sexual harassment, including demanding sex in return for favors; sexual abuse of mentally or physically disabled people; sexual abuse of children; forced marriage or cohabitation, including the marriage of children; denial of the right to use contraception or to adopt other measures to protect against sexually transmitted diseases; forced abortion; violent acts against the sexual integrity of women, including female genital mutilation and obligatory inspections for virginity, forced prostitution and trafficking of people for the purpose of sexual exploitation2.

Sexual violence is defined as, “any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic women’s sexuality, using coercion, threats of harm or physical force, by any person regardless of relationship to the victim, in any setting, including but not limited to home and work”3.

mouth of another person without their consent. Marital rape, incest and rape of a minor are all included under this definition.

Attempted rape/attempted sexual assault: Efforts to rape someone that do not result in penetration are considered attempted rape or attempted sexual assault.

Sexual abuse: The actual or threatened physical intrusion of a sexual nature, whether by force or under unequal or coercive conditions.

Sexual assault: When a person touches with any part of his or her body or with an object manipulated by him or her the sexual parts of another person, including the genital area, groin, buttocks and breast, without their consent.

Survivor/victim: Person who has experienced sexual gender-based violence. The terms ‘victim’ and ‘survivor’ are often used interchangeably. ‘Victim’ is a term often used in legal documents and procedures, but the stigmatisation and perceived powerlessness associated with being a victim means the term is often exchanged for survivor. Literally, a survivor is a person who has overcome a deadly threat, be it violence, disease or accident; in relation to sexual violence, it is often used to describe a living victim, even of usually non-fatal harm, out of respect for their strength and resilience, and to help them heal and feel empowered. The term survivor is used because it focuses on agency, strength, resiliency and empowerment.

Perpetrator/aggressor/assailant: Person, group or institution that directly inflicts or otherwise supports violence or other abuse inflicted on another against her/his will.

Rape: is forced, coerced or non-consensual penetration of the vagina, anus or mouth – however slight – with the penis, other Child or minor: Child or minor: Person under the age of 18, body part or an object. (Interagency Standing Committee, according to the United Nations Convention on the Rights of 2015) (al, 2002). It’s an act of non-consensual sexual intercourse the Child4. using force or the threat of force or punishment. This includes the penetration, to any extent, by a person of his penis into the vagina, anus or mouth of another person without their consent 1 IASC, 2015. and the introduction by a person of any object or a part of his 2 WHO, 2017 3 Jewkes et al, 2002 or her body (other than the penis) into the vagina or anus or 4 UNGA, 1989

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Consent: Informed consent is the expressed willingness to participate in services of an individual who has the legal capacity to give consent. Parents are typically responsible for giving consent until their child or adolescent reaches 18 years of age. In some settings, older adolescents are also legally able to provide consent instead of, or in addition to their parents.

Accronyms: MSF: Médecins Sans Frontières PEP: Post-exposure prophylaxis (for HIV) POZ: Promoteurs Objectifs Zero-Sida SGBV: Sexual and Gender Based Violence

References Amnesty International, Don’t Turn Your Back on Girls: Sexual Violence Against Girls in Haiti, 2008 Anne-Christine d’Adesky, Beyond Shock: Charting the landscape of sexual violence in post-quake Haiti: Progress, Challenges & Emerging Trends 2010-2012, PotoFanm+Fi November 2012 Cayemittes, Michel, Michelle Fatuma Busangu, Jean de Dieu Bizimana, Bernard Barrère, Blaise Sévère, Viviane Cayemittes et Emmanuel Charles, Enquête Mortalité, Morbidité et Utilisation des Services, Haïti, 2012. Calverton, Maryland, USA : MSPP, IHE et ICF International, 2012 Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, PEPFAR - U.S. President’s Emergency Plan for AIDS Relief, Republic of Haiti, Together for Girls, The Interuniversity Institute for Research and Development, Violence Against Children in Haiti: Findings from a National Survey 2012, June 2014 Dunkle, Jewkes, Brown, et al., “Prevalence and patterns of gender-based violence and revictimization among women attending antenatal clinics in Soweto, South Africa” in Am J Epidemiol, 2004 Fox, Chanelle, "Violent Sex: How Gender-Based Violence is Structured in Haiti, Healthcare & HIV/AIDS," Indiana Journal of Law and Social Equality: Vol. 2: Iss. 1, Article 10, 2013 Governance and Social Development Resource Centre, Helpdesk Research Report: Violence against women and girls in Haiti, 2013 Human Rights Watch, “Nobody Remembers Us”: Failure to Protect Women’s and Girls’ Right to Health and Security in Post-Earthquake Haiti, 2011 Human Rights Section (HRS), Office of the High Commissioner for Human RightsHaiti, A Profile of Police and Judicial Response to Rape in Port-au-Prince, Office of the High Commissioner for Human Rights, Haiti: Port au Prince, 2012 Inter-Agency Standing Committee (IASC). Guidelines for Integrating Gender-based Violence Interventions in Humanitarian Action. (2015) Jewkes R, Garcia-Moren C, Sen P. Sexual violence. In: World report on violence and health. Geneva, World Health Organization, 2002:149–181.

Joshi, Rahill, Lescano, Jean, “Language of Sexual Violence in Haiti: Perceptions of Victims, Community-level Workers, and Health Care Providers” in Journal of Health Care for the Poor and Underserved, Volume 25, Number 4, November 2014, pp.

1623-1640 Nolan, C., “Haiti, Violated”, World Policy Journal, 28: 93, 2011 Unité de Recherche et d’Action Médico Légale, Renforcement des capacités des acteurs jouant un rôle dans la réponse à la violence sexuelle et sexiste, Port-auPrince, Haiti, Février 2013 United Nations General Assembly (UNGA). Convention on the rights of the child, Treaty Series, 1577:3. New York, United Nations, 1989.

WHO. WHO Ethical and safety recommendations for researching, documenting and monitoring sexual violence in emergencies. World Heal. Organ. (2007). doi: ISBN 978 92 4 159568 1 World Health Organization (1999). Report of the Consultation on Child Abuse Prevention, 29-31 March 1999, WHO, Geneva. Available at: http://apps.who.int/ iris/bitstream/10665/65900/1/WHO_HSC_PVI_99.1.pdf WHO. Guidelines for medico-legal care for victims of sexual violence (WHO 2003). http://www.who.int/violence_injury_prevention/resources/publications/en/ guidelines_chap7.pdf World Health Organization (WHO), Violence against women: Definition and scope of the problem, July 1997 AGAINST THEIR WILL 25

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